Psychiatry Residents’ Orientation Manual

attendance at conferences; other reasons for non-attendance should bediscussed with the instructor. If a resident’s attendance falls below athreshold of 70%, this will lead to a conference with the program director.If attendance does not improve over the next period of monitoring, thisissue will be taken to the education policy committee where this will beassessed and a course of action will be determined.POLICIES FOR EVALUATION AND PROMOTION OF RESIDENTSEvaluations are completed for each rotation of residents throughout theirtraining. These evaluations have assessment components of knowledge,skills, and work-related behavior, in accordance with the ACGME corecompetencies. Faculty are encouraged to comment upon strengths andareas for further work or remediation. Further, faculty are encouraged todiscuss the evaluation directly with the resident. For year-long rotations,evaluations are collected at six month intervals. This includes serviceevaluations as well as evaluations by supervisors.Residents have a formal meeting with the program director twice yearly.At this meeting, all evaluations are discussed and any problemsaddressed. All residents must take the Psychiatry Residency In-ServiceTraining Examination (PRITE) in September or October, and the resultsare discussed individually at the mid-year meeting with the programdirector. If a resident scores below the 25th percentile in psychiatry,attendance at the PRITE review course will be mandatory. In addition,there is a yearly clinical examination of a patient interview followed by aquestion and answer session. These are done in the style of the ABPNOral Board Examination and given by faculty who are Board Examiners.If there are problems identified in the midst of a rotation, faculty areinstructed to either talk with the resident alone or seek consultation of theprogram director. If there is an unsatisfactory evaluation, the EducationPolicy Committee (chaired by the program director) considers what courseof action to pursue. This may include remediation, repeating the rotation,and/or probation, in accordance with our due process procedures. If thereare multiple unsatisfactory evaluations in a given year, and efforts atremediation have been unsuccessful, the Education Policy Committee willevaluate whether the resident will be permitted to advance to the next yearof training. This will be an ongoing process, discussed with the resident.Successful completion of the training program is dependent uponsatisfactory completion of all required and elective rotations. In addition, itmust be determined that there has not been a pattern of unethicalconduct, and that the resident is judged competent to practiceindependently.

VACATION POLICYOurs is a small and busy department where the absence of an individualresident has a significant impact upon the operation of a clinical area. It isessential to have general guidelines for Housestaff vacation. Pleaseconsider these guidelines so that clinical areas can be run as smoothly aspossible:PGY-IVacation scheduling is not an issue during the PGY-I year becausevacation time is assigned. In general, this is done in two segments of twoweeks each. In practice, trades of time are possible but this must be donethrough the office of the Medial Director. This involves finding someonewho has vacation scheduled during the desired time and then making theappropriate switch.PGY-II through IVFor years II through IV vacations have not been assigned and residentsare free to attempt to take vacation when they please. However, thefollowing guidelines must be kept in mind.1. It is generally not feasible to take all 24 vacation days together.This would seriously interfere with a resident's ability to deriveappropriate educational benefit from a given rotation.2. The amount of vacation taken on any given service should beproportional to the length of that particular rotation. With advanceplanning it might be possible to join two blocks of vacation into onelonger vacation if one takes vacation during

the final week or weeks of one rotation and the initial week orweeks of a subsequent rotation.3. In order to be fair to all concerned (the residents and the faculty)vacations should be requested at least thirty days in advance andpreferably prior to the start of a rotation so that the Chief of theclinical area or team leader can be aware ahead of time of theneeds of that service.4. Vacation must be approved by the Chief of the clinical area or theteam leader, the Chief Resident, and the Director of ResidencyTraining. Vacation request forms are obtained from the office ofResidency Training and, after obtaining the necessary signatures,are returned to the office of Residency Training.5. It must be understood that patient care responsibilities takepreference in the scheduling of vacation and the ultimate decisionregarding scheduling of vacations rests with the Chief of the clinicalarea or team leader. (This is in keeping with the Memorandum ofUnderstanding between Housestaff and the Board of Supervisors).6. Those residents (PGY-II through IV) who so desire may defer up toten working days of vacation each year and accrue this to the endof their training at which time a lump sum payment will be made forthis accrued time (maximum payoff is 10 days for each year). Hispayment will be calculated at the resident’s highest level ofcompensation.7. PGY-IV residents will not be allowed to save all their vacation timefor the month of June. Chaos would result if such a practiceoccurred. Therefore, unless individually approved by the teamleader, PGY-IV’s will be limited to 10 days only of approvedabsence during the month of June.MEETING TIMEMeeting time is not available to postgraduate physicians. We vigorouslyencourage postgraduate physicians to attend high quality professionalmeetings. However, you must understand that this can be done only byutilizing vacation time.

DUE PROCESS PROCEDURE FOR POST GRADUATE PHYSICIANSWITH CLINICAL DEFICIENCIESThere is no issue that is more sensitive and difficult to handle than that ofthe resident experiencing deficiencies. It is the avowed purpose of theEducation Policy Committee to support education, and thus we attempt tohelp any resident who is experiencing performance difficulty to remedythat deficit. Unfortunately, this is not always possible and, on occasion, itmay be necessary for trainees to leave the program. While eachparticular case is different, the following is a set of general guidelineswhich the Education Policy Committee will follow in order to be as fair aspossible to everyone concerned.1.Residents receive written evaluations on each of their clinicalservices. If the Chief of a clinical area or team leader feels thata resident’s performance is deficient, it is the Chief’sresponsibility to counsel the involved resident. This is to bedone before the end of the clinical rotation and in writing. Thiswill be sent to the Director of Residency Training who will reviewit. It is obviously not fair to a resident to complete an entirerotation and then find out only then of deficient performance.2.When the Director of Residency Training receives such anevaluation from the Chief of a clinical area or from a teamleader, that clinical area Chief or team leader and involvedresident will be invited to the next meeting of the EducationPolicy Committee for discussion.3.If after reviewing this information, members of the EducationPolicy Committee agree with the evaluation that there rareserious questions as to the competence or behavior of theinvolved resident, a period of probation will be initiated.4.Probation should not be viewed as a period of punishment butrather as a period of evaluation, review and additional teachingof the involved resident. From the point of view of the facultythis is a period during which the resident will be observed morecarefully by additional supervisors (as designated by theEducation Policy Committee) in order to acquire a moreaccurate picture of the resident’s performance. For the residentthis is a period during which he or she may demonstrate to thedepartment that the suggested deficiencies are exaggerated orthat progress is being made to remedy them.5.There is no fixed time for a period of probation but generally

probation will entail a minimum of at least several months asthis is necessary to obtain the appropriate data. Often probationwill be for a longer period of time.6.At the end of the period of probation, all of the individualsinvolved with supervising the resident will summit writtenevaluations to the Education Policy committee. The EducationPolicy Committee will review these evaluations and can proposeone of three courses: First, removal of probation; second,continued probation; third, dismissal from the program.Obviously this third course is a serious matter and would onlybe recommended for the most problematic of cases such asthose in which deficiencies are of a major degree, clearlyoutlined and documented, and where there is an explicitindication of unsatisfactory progress in remedying thedeficiency.

MOONLIGHTING POLICYMoonlighting under the auspices of the department of psychiatry on the groundsof Harbor-UCLA (the psychiatric emergency room) is allowed for all licensedresidents.Outside moonlighting is not under the supervision of the teaching faculty and isnot allowed by any residents before their PGY-IV year.PGY –IV residents considering moonlighting must submit a written proposal tothe education policy committee showing that the work is outside of County hours,there is appropriate coverage, and the scope of practice is not outside of thetrainee’s abilities (usually medication evaluations and follow up). It is understoodthat moonlighting is not done under the auspices of the Department of Psychiatryor the Hospital. This means that the County will provide no malpractice, andfaculty will do no supervision of the work.The applying resident must be judged to be up to date with all of their residencyduties, and the moonlighting must not ethically conflict with the residency duties.An example of moonlighting, which would not be acceptable, is any freestandingoffice practice.If the education policy committee accepts a moonlighting proposal, the residentmust complete the County’s outside employment forms as residents are Countyemployees.We urge you to fully explore the implications of the moonlighting experience,including your malpractice coverage, the method of payment you will receive, thedocumentation of your work, and to consider whether any legal or ethicalboundaries are being violated (such as self referring cases from the county).Again, neither the Department nor the County has any responsibilities (e.g. legal,financial) for your work if you choose to moonlight outside of the hospital.Failure to obtain moonlighting approval, or misrepresenting moonlighting dutieswill result in disciplinary action against the resident.The administrative review for moonlighters is the same as it is for psychiatrictrainees in performing their other duties. Moonlighting is a valuable financialresource for residents, and it is not offered or allowed at many other institutions.We want to make sure that assignment of moonlighter shifts is done judiciouslyand that those who participate in our moonlighting program maintain anacceptable standard of practice and performance.1. Moonlighters perform an important, valued function in our call system.Therefore, remuneration should be equitable.2. Moonlighters will be held to the following standards of practice:a. Moonlighters will be required to be on campus throughout theirassigned shifts.b. Moonlighters will be required to be available to the other residentsat all times for overflow patient evaluation and management, foradvise and second-opinion, and for MER and ward consultations.

c.d.e.f.A helpful and supportive attitude should be considered standardpractice.There will be no “protected time” for moonlighters. The splittingof nighttime and weekend shifts into resident and moonlighter subshifts will not be prohibited, but the moonlighter will be expectedto provide back-up support to his fellow residents wheneverneeded, regardless of shift status.Moonlighters will be required to conduct complete andcomprehensive evaluations of their patients.i. HPI must make every effort to include the “who, what,why, where, and when” with respect to presentation andcomplaints. HPI must include relevant psychosocialstressors.ii. The five-axes diagnostic summary should be backed bysufficient documentation in the body of the database tojustify diagnostic assertions.iii. Every effort must be made to complete physical exams ofpatients. Documenting “Refused.” will be consideredinsufficient.iv. Comprehensive medication management anddocumentation of justification for medications (or lackthereof) will be required.v. 5150 involuntary holds and written advisements must becomplete and accuratevi. Every effort must be made to contact appropriate collateralsources of information.vii. Discharge summaries must include sufficient evidence ofmedical and behavioral stability for transfer or discharge.Moonlighter administrative performance review and evaluationwill include all of the following:i. Psychiatric ER director will randomly review in the AMdocumentation of emergency evaluations and treatmentplans conducted overnight by moonlighters. Deficiencies indocumentation will be recorded.ii. Concerns expressed by other residents will be documented.iii. All of the above will be evaluated over time for patterns ofdeficiency.If patterns of deficiency are suspected, administrative review willinclude the following in the following order:i. The moonlighting resident will be privately informedverbally and in writing that a one-month probationaryperiod has been instituted to evaluate suspecteddeficiencies. During this time, the attending will providespecific recommendations and both positive and negativefeedback regarding performance.ii. During the probationary period, every evaluation andtreatment regimen by the moonlighter will be reviewed anddeficiencies will be registered.iii. Following completion of the probationary period, ThePsychiatric ER Director and the Residency Director willanalyze accrued information to assess for continuedpatterns of deficiency.

iv. If both the Residency Director and the Psychiatric ERDirector agree that deficiencies represent an unacceptablepattern of behavior, moonlighter privileges will besuspended for a period of six months.v. Following suspension period, suspended residents mayreapply for moonlighting, but the first month ofmoonlighting will include another one-month probationaryperiod to reassess performance.

GENERAL COMPETENCIESAt its February 1999 meeting, the ACGME endorsed general competencies forresidents in the areas of: patient care, medical knowledge, practice-based learningand improvement, and interpersonal and communication skills, professionalism,systems-based practice.Identification of general competencies is the first step in a long-term effectdesigned to emphasize educational outcome assessment in residency programsand in the accreditation process. During the next several years, the ACGME’sResidency Review and Institutional Review Committees will incorporate thegeneral competencies into their Requirements.ACGME GENERAL COMPETENCIES Vers. 1.3(9.28.99)The residency program must require its residents to develop the competencies inthe six areas below to the level expected of a new practitioner. Toward this end,programs must define the specific knowledge, skills, and attitudes required andprovide educational experiences as needed in order for their residents todemonstrate the competencies.PATIENT CAREResidents must be able to provide patient care that is compassionate, appropriate,and effective for the treatment of health problems and the promotion of health.Residents are expected to:communicate effectively and demonstrate caring and respectful behaviorswhen interacting with patients and their families;gather essential and accurate information about their patients;make informed decisions about diagnostic and therapeutic interventionsbased on patient information and preferences, up-to-date scientificevidence, and clinical judgment;develop and carry out patient management plans;counsel and educate patients and their families;use information technology to support patient care decisions and patienteducation;perform competently all medical and invasive procedures consideredessential for the area of practice;provide health care services aimed at preventing health problems ormaintaining health;work with health care professionals, including those from otherdisciplines, to provide patient-focused care.

MEDICAL KNOWLEDGEResidents must demonstrate knowledge about established and evolvingbiomedical, clinical, and cognate (e.g. epidemiological and social-behavioral)sciences and the application of this knowledge to patient care. Residents areexpected to:demonstrate an investigatory and analytic thinking approach to clinicalsituations;know and apply the basic and clinically supportive sciences which areappropriate to their discipline.PRACTICE-BASED LEARNING AND IMPROVEMENTResidents must be able to investigate and evaluate their patient care practices,appraise and assimilate scientific evidence, and improve their patient carepractices. Residents are expected to:analyze practice experience and perform practice-based improvementactivities using a systematic methodology;locate, appraise, and assimilate evidence from scientific studies related totheir patient’s health problems;obtain and use information about their own population of patients and thelarger population from which their patients are drawn;apply knowledge of study designs and statistical methods to the appraisalof clinical studies and other information on diagnostic and therapeuticeffectiveness;use information technology to manage information, access on-line medicalinformation;support their own education;facilitate the learning of students and other health care professionals.INTERPERSONAL AND COMMUNICATION SKILLSResidents must be able to demonstrate interpersonal and communication skillsthat result in effective information exchange and teaming with patients, theirpatient’s families, and professional associates:Residents are expected to:create and sustain a therapeutic and ethically sound relationship withpatients;use effective listening skills and elicit and provide information usingeffective nonverbal, explanatory, questioning, and writing skills;work effectively with others as a member or leader of a health care teamor other professional group.PROFESSIONALISMResidents must demonstrate a commitment to carrying out professionalresponsibilities, adherence to ethical principles, and sensitivity to a diverse patientpopulation. Residents are expected to:demonstrate respect, compassion, and integrity;a responsiveness to the needs of patients and society that supersedes selfinterest;

accountability to patients, society, and the profession;a commitment to excellence and on-going professional development;demonstrate a commitment to ethical principles pertaining to provision orwithholding of clinical care, confidentiality of patient information,informed consent, and business practices;demonstrate sensitivity and responsiveness to patient’s culture, age,gender, and disabilities.SYSTEMS-BASED PRACTICEResidents must demon

addressed. All residents must take the Psychiatry Residency In-Service Training Examination (PRITE) in September or October, and the results are discussed individually at the mid-year meeting with the program director. If a resident scores below the 25th percentile in psychiatry, attendance a